The COVID-19 health care emergency has spawned another crisis that will worsen in the short term and will have profound implications going forward: Older adults in America are facing a mental health crisis due to lack of access to Medicare providers and needed services.

This provider shortage persists as uncertainty surrounding the COVID-19 pandemic has resulted in significant increases in anxiety and depressive disorders among older adults. Between 25-30% (or 20 million) older adults have reported these mental health disorders since April 2020.¹ Physical distancing and quarantine have led many older adults and caregivers to feel isolated, lonely, agitated, and withdrawn.

The members of the National Coalition on Mental Health and Aging have witnessed a significant increase of mental health conditions in older adults due to the snowballing effects of social isolation leading to trauma, anxiety, and depression.

Unfortunately, millions more likely go undiagnosed, as the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Academy of Medicine have found that less than 50% of older adults with mental and/or substance use disorders receive treatment.^2,3

The ongoing opioid crisis has only contributed to this trend, and it is estimated that 5.7 million adults over the age of 50 will require treatment for a substance use disorder in 2022.⁴ 

Action is needed now to address the needs of aging Americans with mental health conditions and prepare for substantially more Medicare beneficiaries developing depressive and anxiety related disorders.

New research shows that not only are Medicare beneficiaries at a high risk for opioid misuse and addiction, but they are also not receiving adequate treatment, and, as a result, overdose and end up in the hospital.

The National Coalition on Mental Health and Aging is dedicated to addressing the needs and promoting the interests of aging Americans with mental health conditions and addressing the problems older adults have in accessing needed mental health services. The Coalition is composed of 70 national and state organizations, professional associations, and federal agencies that represent the behavioral health interests of older adults with mental health conditions. We provide a forum for sharing, learning and technical assistance for professionals in behavioral health, the aging network, consumer advocates, and government. The Coalition provides opportunities for members to work together toward improving the availability and quality of mental health and preventive and treatment strategies for older adults and their families through education, research, policy analysis, and public awareness.  

The Coalition has identified several priorities to address the needs of older adults with mental health conditions.

How we can strengthen the mental health workforce to serve older adults

The Coalition believes critical strategies to address the current and future shortfall in providers who are trained in geriatrics and mental health include:

It is critically important to address workforce shortages in rural and other underserved areas by incentivizing behavioral health providers to practice in these areas.  

In addition, consideration should be given to expanding Medicare’s provider network to include mental health counselors, marriage and family therapists, peer recovery support specialists, and other licensed behavioral health specialists.

Medicare does not reimburse for services provided by mental health counselors or marriage and family therapists. These two professions make up approximately 40% of the licensed behavioral health workforce in the United States.⁵ They are covered by all other insurance providers, both public and private, aside from Medicare. With these two professions shut out of the largest insurer in the country, Medicare beneficiaries do not have sufficient access to mental health treatment.

Mental health counselors and marriage and family therapists are qualified to provide needed services and are already an integral part of the mental health care delivery system in the United States.

Access to mental health treatment for Medicare beneficiaries in rural areas is especially lacking. As of 2022, over 150 million people in the United States live in Mental Health Professional Shortage Areas, according to the Health Resources and Services Administration.⁶ Fifty percent of rural counties in America have no practicing psychiatrists, psychologists, or social workers. Research shows that mental health counselors and marriage and family therapists are much more likely to be in these rural areas than any other practitioner.⁷

Why we should coordinate mental and primary health care

The Coalition also recommends that Medicare and Medicaid financing mechanisms should be restructured to support the integration of behavioral health and primary care for aging Americans and to support interdisciplinary care coordination and treatment teams.

The 2012 Institute of Medicine Report “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” concluded that Medicare and Medicaid coverage policies were a significant financial barrier for aging Americans in obtaining care for mental illness and substance use disorders. Due to the current and projected future shortage of behavioral health specialists, much mental health care will need to be provided through behavioral health and primary care integration and by interdisciplinary care coordination and treatment teams, which include multiple health care professionals.  

A strong body of evidence shows that integrated care models like Collaborative Care, which integrates depression care into general medical settings, can improve behavioral health treatment delivery and outcomes for older adults.

The Patient Centered Medical Home (PCMH) is a health care delivery model designed to improve treatment of several chronic conditions, including, but not limited to, mental health conditions. Research suggests it has the potential to improve both mental and physical health care for people with mental illness. The Coalition recommends that primary care doctors and specialist receive financial incentives for participation in the PCMH.

The Coalition also recommends statutory changes to Medicare related to eliminating the limits on inpatient psychiatric hospital care.

Why continuing Medicare coverage for  tele-mental health services is important for older adults

Medicare tele-mental health coverage has been substantially expanded in response to the COVID-19 pandemic, with the majority of services, including group counseling, covered by Medicare and reimbursed at the same rate as in-person services. Medicare policy changes also have enhanced accessibility of tele-mental health services by:

• Waiving originating-site requirements and thus allowing beneficiaries to receive telemedicine services from home.
• Waiving HIPAA requirements that tele-mental health services be delivered over secure, audiovisual software platforms and instead permitting delivery by telephone/other means.
• Allowing providers to conduct tele-mental health visits with new patients.
• Allowing providers licensed in one state to deliver telemedicine services to consumers in a different state.

As of May 2022, it is unclear whether these policies will be continued once the COVID-19 pandemic abates. The Coalition recommends that these policies remain in effect permanently.

When we ensure parity between behavioral and physical health care older adults benefit

The Coalition recommends that mental health parity apply to all current and future public and private payers including Medicare, Medicaid fee-for-service, TRICARE, and Indian Health Services. The Mental Health Parity and Enforcement Act (MHPAEA) would make this possible.

Medicare Advantage criteria for network adequacy should be revisited with the goal of improving access to in-network specialty mental health providers. To aid consumers in identifying plans with adequate networks, the Centers for Medicare and Medicaid Services could incentivize plans to make comprehensive, up-to-date provider directories available by incorporating measures of directory adequacy in their Star Rating System. In addition, few Medicare Advantage plans are offered for people with serious mental illness. 

Let's urge Congress to increase funding of the Older Americans Act

The Older Americans Act (OAA) funds critical services that keep our nation’s older adults healthy and independent. These services include meals, job training, senior centers, health promotion and disease prevention programs, benefits enrollment, caregiver support, transportation, and more. Such services and programs address social determinants of health that are critical to the health and quality of life for older persons with behavioral health concerns. OAA services focus on meeting the needs of low-income and underserved older adults, who are also most at risk for mental health conditions.

The Administration for Community Living/Administration on Aging, which administers the OAA, in conjunction with SAMHSA, could be tasked with disseminating and funding models and funding strategies that better integrate the aging network and behavioral health communities.    

How do we improve older adult mental health care in the post COVID-19 era?

With the approaching demographic change, we will witness an unprecedented increase in the number of aging Americans with mental health and substance use disorders over the coming decades. The stressors brought on by the COVID-19 pandemic have increased mental health service needs.

It is imperative that the Medicare program be modernized and other critical changes take place as described in the recommendations above in order and help provide aging Americans with the mental health services they deserve.

The time to act is now.

NCOA hosts the annual Older Adult Mental Health Awareness Day to highlight critical issues in addressing mental health needs as we age. 

This article is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $5 million with 100% funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.

Sources

1. Kaiser Family Foundation. One in Four Older Adults Report Anxiety or Depression Amid the COVID-19 Pandemic. Wyatt Koma, Sarah True, Jeannie Fuglesten Biniek, Juliette Cubanski, Kendal Orgera, and Rachel Garfield.  Oct. 9, 2020. Found on the internet at https://www.kff.org/medicare/issue-brief/one-in-four-older-adults-report-anxiety-or-depression-amid-the-covid-19-pandemic/

2. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. 2020 Sep (Report No. PEP20–07-01-001). Found on the internet at https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf

3. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Jill Eden, Katie Maslow, Mai Le, and Dan Blazer, Editors; Committee on the Mental Health Workforce for Geriatric Populations; Board on Health Care Services; Institute of Medicine. National Academies of Science, 2012. Found on the interent at https://www.aagponline.org/clientuploads/IOM%20July%202012%20Report%20Full.pdf

4. Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers. William J. Parrish et al. American Journal of Preventive Medicine. March 2022. Found on the internet at https://www.sciencedirect.com/science/article/abs/pii/S0749379722001040

6. Shortage Areas. Health Resources and Services Administration. Health Professional Shortage Area National Summary. Found on the internet at https://data.hrsa.gov/topics/health-workforce/shortage-areas

7. A call to action to address rural mental health disparities. Dawn A. Morales, Crystal L. Barksdale, and Andrea C. Beckel-Mitchener. Journal of Clinical and Translational Science. Published online May 4, 2020. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7681156/